Microsoft word - jan_2013_pre-school_application_form1.doc

Hendreds Pre-School
Snells Hall, Church Street, East Hendred, Oxon OX12 8LA Tel: 01235 831555 / 07956 911413 Email: [email protected] Web: www.hendredspreschool.org.uk Registered Charity No: 1023329 Application Form
Child’s Full Name……………………………………………Date of Birth………………………….…………… Address (inc. postcode)…………………………………………………………………….……………………. ……………………………………………………………………………….…Postcode…………….…………. Name of Parent(s)/Guardian(s)……………………….………………………….………………….………. Address (if different from child's)………………………………………….….……………………….………. Home Telephone No………………………………………….Mobile No………….……….……….………… Work Address (if applicable)………………………………………………….……………………….………. Work Telephone No…………………………………………………….….….……….…………….………… Child’s first language……………….……………Other language(s) spoken at home………………………. Email address………………………………………………………………………………………………………. Name of any parent who does not have legal access to your child.…….…….……………………….……. Persons authorised to collect your child if different from above: (Please include anyone who will regularly collect your child i.e. childminder or grandparent) Name & Relationship ……….……………………………….…………… ……………….………….….….… Address ……….…….………………………….…… We produce a telephone list for all parents, please indicate if you are interested in being included. We would like / would not like to be included on the telephone list.
Emergency Contacts
Please provide alternative contact details in case you are unavailable e.g. a grandparent or friend Name & Relationship ……….……………………………….…………… ……………….………….….….… Name & Relationship ……….…………………………….…………….… ……………….…….……….….… Name & Relationship ……….………………………….………………….
……………….………….….….… Medical Details
Name of Doctor………………………………………………………. ………………………………………. Address…………………………………………………………………………………………………….………. Does your child have any medical conditions? (please list)….……….….………………………….………. ……………………………………………………………………………………………………….…….………… Does your child have any allergies or intolerances? (please list)….…………………….…………………. ……………………………………………………………………………………………….…….………………… Does your child require any prescription drugs or medicines e.g. Ventolin? (please list) ………………………………………………………………………………………………………….……….…… Please note pre-school staff cannot administer drugs or medicines. If this will prevent your child from attending pre-school please let us know and we will try to make special arrangements. Personal Care
Does your child have special dietary needs or preferences? ……………….………………………………… ………………………………………………………………………………………………………………………… What is the main religion in your house?………………………………………………………………………. Does your child have any special need, which you would like to discuss with staff?………………………………………………………………………………………….…………………. We welcome children at all stages of development including those who are still wearing nappies, having occasional ‘accidents’ or needing support with personal care. Names of any professionals involved your child (e.g speech therapist etc.)
Name 1 & Role ……….…………………………….…………………………….………….….….… Agency ……….…………………………….….…………… ……………….………….….….… Name 2 & Role ……….…………………………….…………………………….………….….….… Agency ……….…………………………….….…………… ……………….………….….….… Name & based at………………………….….…………… ……………….………….….….… Does your family have a social worker for any reason? Name & based at………………………….….…………… ……………….………….….….… What is the reason for the involvement of the social care department with your family? ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… NB If the child has a child protection plan, make a note here, but do not include details. Ensure these are obtained from the social care worker named above and keep these securely in the child's file. Sessions
Please tick the sessions and fill in the start date you would prefer. Children can start at pre-school the term after they turn two so there are six intakes a year. Please be aware that although we aim to accommodate, this is only a request from you and we will confirm days closer to your starting date depending on the waiting list. We recommend that your child attends 2 or 3 sessions per week to begin with. This can be increased as your child settles in. Morning sessions begin at 9.00am and finish at 12 noon. Afternoon sessions begin at 12 noon and finish at 3.00pm. The government’s free nursery funding of 15 hours a week comes into effect the term after your child turns three. Fees: 2 year olds -
Afternoon Sessions
We run afternoon sessions depending on having sufficient numbers. Afternoon sessions run from 12.00
– 3.00pm. Children are able to do two sessions in a day and remain at pre-school from 9.00am –
3.00pm bringing their packed lunch. If your child only attends an afternoon session, please also bring a
packed lunch.
Lunch Club
As well as the above sessions we can also offer your child ‘lunch club’ which runs every day
12 – 1.00pm. If lunch club falls within your 15 grant funded hours per week, it will be free. Otherwise the
sessions cost £4.50 for two year olds and £3.73 for three year olds. Any hours over and above the 15
hours are £3.73 per hour. It will be invoiced at the start of each term. Your child will need to bring a
packed lunch. The running of these sessions will be reviewed at the start of term, depending on
numbers, but if you are interested please tick the ‘lunch club’ box below.
Please tick the sessions you require below:
Monday morning
Other sessions not currently available: Monday afternoons*
2012/13 Term Sessions* These sessions are dependent on the number of parents wanting them so may not always be
available.

Preferred start date…………….……………………………………….…………………………………………
All about me

You will be asked to provide information about your child so that the early years practitioners within the
pre-school have some reliable background knowledge of your child and your child’s key worker can
prepare for your child’s arrival. This form will be sent to you before your child starts, please can you
ensure that you send it back as soon as possible.
Finally where did you hear about the pre-school?………………….……………………………………………
Parent’s Declaration (please read carefully)
I understand that whilst my child is two the cost is £4.50 per hour, which is £13.50 a session. When
my child turns three and until funding begins, the cost is £3.73 per hour, which is £11.19 a session.
When my child is entitled to funding ie from after their third birthday (see below) he/she is entitled to 15
hours of early education per week funded by the Local Authority (LA). I understand that the fees are
charged whether or not my child attends a particular pre-school session whilst their name is on the pre-
school register. Any hours over and above the 15 hours are £3.73 per hour.
Children who turn three between 1 April – 31 August are eligible for free funding in September Children who turn three between 1 September – 31 December are eligible for free funding in January Children who turn three between 1 January – 31 March are eligible for free funding in April
I will give one term’s notice in writing to have my child's name removed from the register. If the
required notice is not given I will be liable to pay one term’s fees (if my child is not LA funded).
I agree not to bring my child to pre-school if he/she is obviously unwell or suffering from an infectious
disease, or has been in contact with someone suffering from an infectious disease.

I understand that pre-school go out in all weathers and I will provide appropriate clothes. Pre-school staff
may take the children for walks around the villages of East and West Hendred, to the shop, to the
playground or to the mobile library. Children will be fully supervised when away from pre-school
premises. The ratio of adults to children will be no less than 1 to 2 for two year olds and 1 to 6 for three
year olds in accordance with legal requirements. I agree that my child may participate in these activities.
I confirm that the above details are complete and correct to the best of my knowledge. In the unlikely event of illness or accident I give permission for any necessary medical treatment to be given. In an emergency and if I cannot be contacted, I am willing for my child to receive hospital treatment, including anaesthetic and blood transfusion if necessary. I understand that every effort will be made to contact me as soon as possible. A member of staff from the pre-school will accompany my child and stay with them until my arrival.
I would like my child to join the Hendreds Pre-School and agree to abide by the constitution of the
pre-school (available on request).
I enclose the registration fee of £10 payable at enrolment; (cheques made payable to Hendreds Pre-
school)

Policies and Information Sharing
I have been provided with the list of the pre-school’s policies and procedures, including the Information Sharing policy and understand that there may be circumstances where information is shared with other professionals or agencies without my consent. (Any policy including the Information Sharing policy is available on request to the pre-school chairman.)
Signed……………………………….…….Name………….……………….……………….…
Copyright Release and Use of Images - Photographs and Videos
The pre-school may produce web pages, presentations, educational or interest articles for magazines or
similar. Your child's work will never be used without your permission. Photographs (these may be as
group shots or photographs of the individual child) are often used in various in-house publications such
as our prospectus and also form an important part of our displays in school and our record keeping. We
require parental permission to be able to publish these. Your child's safety will always be of paramount
importance therefore under no circumstances will personal information be made public. We currently do
not use photographs of children on our website.
Please sign below if you are happy for your child's work/image to be shared in this way.
I give consent to the pre-school to publish my child's work or image subject to strict
confidentiality of personal information.

Signed……………………………………………………….Name………….……………….…………….…
Monitoring
As an Ofsted registered pre-school we want to be sure that we are reaching the full range of local families. Please help us to do that by answering these few questions in confidence: Your child’s date of birth………………….………Your child’s gender……………………………….……….
Please indicate below the ethnic origin of you child. Tick just ONE box
(Categories supplied by the Commission for Racial Equality)
White – British
Irish
Traveller of Irish Heritage
Gypsy/Roma
Any other White background
Mixed – White and Black Caribbean
White & Black African
White & Asian
Any other Mixed background
Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background
Black or Black British
Caribbean
African
Any other Black background
Any other ethnic background. Please state…………………………………………………

Parental Help
As a registered charity there are inevitably times when we ask parents for help in order to minimise our
running costs. Please indicate if you would be willing and able to help with any of the following areas or
let us know if you have particular skills that may be useful. Thank you.
Working on the committee Helping with fundraising, e.g. cake-making or running a stall at the fete Solving computer problems/ installing new IT equipment Assembling flat-pack furniture or play equipment Taking part in outings Other…………………………………………………………………………………………………….
Data Protection

The Hendreds Pre-School processes personal data about its attendees and is a “data controller” under
the Data Protection Act 1998. It holds and processes this data to:
support attendees’ individual needs, and
This data includes contact details, attendance information, characteristics such as ethnic group, special
educational and care needs including medical information.
This data may only be used or passed on for specific purposes stated by law. From time to time the
pre-school may be required to pass on some of this data to public bodies such as Ofsted, who is also a
data controller, in respect of data received and who are subject to the same legal constraints in their use
of this data.
Please be assured that data will be held in the strictest confidence and under the terms of the Act. If you
wish to have access to any of the personal data held on you or your child, please submit any requests in
writing to the Chair of the Pre-School Committee.
Signed……………………………….…….Name………….……………….……………….…
Relationship to child…………………………….……….Date……….……….……………………………
Please return the completed form to: Kate Swanzy, 3 Kings Lane, Harwell, OXON, OX11 0EJ
01235 833344 / 07799 780732

Source: http://www.hendred.org/pdfs/Pre-school/application_form.pdf